Basic Information
| Provider Information | |||||||||
| NPI: | 1710456025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISSAM HOTEIT MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8440 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436230440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198850200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4841 YOSEMITE PKWY | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435604341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198850200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2018 | ||||||||
| LastUpdateDate: | 11/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOTEIT | ||||||||
| AuthorizedOfficialFirstName: | WISSAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4198850200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0070488 | 05 | OH | MEDICAID |